New medical recommendations, including drugs and surgery, highlight an ongoing debate over whether obesity should be treated as a chronic health condition.
As a teenager, Sean Rutherford was an insomniac. So between midnight and 5 a.m., Rutherford would play Dido and Sarah McLachlan on a Walkman while they walked the entirety of their apartment complex in Lafayette, Louisiana. For an occasional break, they'd sit by the pool. But then it was back to pacing the complex.
Now 35, a professional medium and TikTok creator in New Orleans, Rutherford points to these moments as one example of an active lifestyle led by a kid in a big body that stayed big. Throughout childhood, Rutherford was dragged from pediatrician to nutritionist to dietitian. The food restrictions their mother imposed under medical guidance, combined with the general lack of effective medical treatment or results from any diet, damaged Rutherford's relationship with food and left them with the feeling there was something irreparably wrong with them.
"My relationship with food became my number one reason why I think it was really problematic," Rutherford said of the advice and health care they received as a child. "I find science and medicine doesn't take into account that everyone's body is different."
All the fad diets -- including keto, which was more effective than the others but had to be stopped because it became unaffordable to sustain, as well as two Weight Watchers stints before age 21 -- were similarly unhelpful to Rutherford as an adult. Today, they're looking for the same answers as when they were a kid, coming up against the same barriers in health care and navigating the same thorny conversations about the size of their body.
"You're shut out of doors," Rutherford said of their experience at the doctor's office. "You get your thyroid checked once, they find out there's nothing wrong -- they never want to check it again," Rutherford said. "They don't want to run deeper tests, they don't want to do anything."
In January, for the first time in 15 years, the American Academy of Pediatrics released treatment guidelines for obesity in children, recommending earlier intervention, including obesity medications and surgery in certain cases. This constitutes a dramatic shift away from the "watchful waiting" approach that delayed medical treatment for weight loss and encouraged more lifestyle monitoring by health care providers.
The new guidelines also build on the medical community's precedent for treating obesity as a chronic disease, which has divided expert and public opinion on what it means to have a higher body mass index, as well as whether treating it as a disease lessens the burden on children or piles onto the bias against bigger bodies that already exists in their schools, at their pediatricians' offices, on TV and even in their homes.
The AAP updated its guidelines for pediatricians to include new information and recommendations for weight-loss treatment, including drugs and surgery in some cases. Bariatric or metabolic surgery may now be recommended for some children aged 13 and up. Kids as young as 12 years old can be prescribed medications for weight loss, which are growing in number, in tandem with other care that should address the long list of social determinants of health that can influence the size of a child's body.
In short, the new guidelines discuss obesity as a disease with biological, socioeconomic and environmental factors, as opposed to the stigmatizing idea that obesity is a "reversible consequence of personal choices," as the authors write in the clinical practice guidelines. The guidance, which was published in the AAP's scientific journal Pediatrics, also acknowledges a pervasive stigma against children in bigger bodies by the very providers that treat them.
But some critics say the guidelines may end up adding to the same stigma they call out, and that pediatricians are ill-equipped to carry out the AAP's recommendations for treatment without causing more harm. The health care system at large, too, may not be the best tool for addressing the socioeconomic, racial and other inequities that the AAP authors describe.
"The health care system is an important component of connecting families to resources," Kate Bauer, associate professor of nutrition sciences at the University of Michigan School of Public, told Futurity. But available resources might be "just a Band-Aid," Bauer told the publication, "and an insufficient one at best."
The authors of the guidelines based the recommendations on evidence of effective treatments for reducing the risk of health conditions associated with obesity, including an increased risk of heart disease, diabetes and other health conditions. Dr. Steven Abelowitz, a pediatrician and medical director of the Coastal Kids medical group, said the new recommendations are based in science and are "without a doubt, the most useful objective data we have." However, Dr. Abelowitz said, "I'm not convinced in the first meeting you need to recommend medications or surgery."
The guidance has garnered a lot of backlash from the public. Media headlines and op-eds criticizing the intense recommendations for children include the words "appalling" and "terrify," in part over fear of negative impacts on children's and teens' mental health, which is declining at an alarming rate.
Abelowitz said he understands the conclusions the AAP came to, even if they were jarring. Rates of diabetes in children are rising, as are the number of children with a high BMI, and the interwoven structural and societal barriers that contribute to high BMIs, such as lack of access to nutritional foods, show little, if any, progress of improving.
"It's easy to be a critic," Abelowtiz said of the negative headlines. "But one has to consider: What are the next steps when all else fails?"
Another key part of the guidelines is their "intensive" recommendations around exercise and food in children with higher BMIs. Part of the AAP's behavioral and lifestyle treatment guidance, for example, advises "direct meal preparation" sessions and a certain number of "nutrition, physical activity, and behavior change lessons" over a period of months -- 26 hours of face-to-face treatment over three to 12 months, for example.
Dr. Katherine Hill, a pediatrician and vice president of Equip, a telehealth service for eating disorder treatment, said that one good thing about the guidance in her eyes is "the acknowledgment that it's not the child's fault if they fall into the category of obesity." The bad, however, is that the guidelines "inadequately" address the risk of eating disorders in children who will be treated for their weight.
"There's pretty strong evidence that shows that when children or adolescents are prescribed diets, it increases risk of both eating disorders and obesity," Hill said. One review, for example, found that treating a child's chronic illness with diet was associated with risk of developing an eating disorder or disordered eating pattern. Studies have also found that adolescents who are overweight are more likely to engage in eating disorder behavior, like inducing vomiting or using laxatives, than their peers.
Eating disorders -- the most common being anorexia, bulimia and binge-eating -- have been on the rise post-pandemic. And they affect people with all body sizes. Hill says that in eating disorder in-patient units, where people stay during treatment, "anywhere from 25% to 45% of young people" are in a larger body.
"We've also seen an epidemic of patients with eating disorders who live in larger bodies -- particularly over the past several years," she said. "So it made me concerned that these guidelines would inadvertently lead to an increased rate of eating disorders in this population."
"That's something that a lot of people don't realize -- that eating disorders affect all people, not just thin, white females," Hill explained.
At its most mild, fatphobia in health care means well-intentioned people give bad advice that patients didn't ask for. At its worst, children are shamed for their body size and praised for developing eating disorders. The latter is one of the most common experiences among Hill's patients, who might have developed an obsession or restrictive eating pattern, only to show up to their next doctor's appointment and be celebrated when their doctor sees the number on the scale drop.
"One of the reasons there's been this epidemic of people in larger bodies having eating disorders is because they tend to get positive reinforcement from all of society -- including their medical providers -- in the early phases of weight loss," Hill said. "And that can sort of trigger this spiraling effect where they start to lose weight extremely quickly, and they're still getting positive reinforcement," she added.
Most adults in the US are overweight, according to an estimate by the US Centers for Disease Control and Prevention, which defines "overweight" as having a BMI between 25 and 30. This is a different classification than the one for obesity, which the CDC, as well as the World Health Organization, define as a chronic medical condition of having a BMI of 30 or higher.
For children and teens, the AAP and CDC define obesity as having a BMI at or above the 95th percentile, which includes more than 14 million US kids and teens. "Severe obesity" is defined by the AAP as a BMI of at least 120% greater than the 95% percentile. These definitions are key to the medication and surgery aspect of the AAP's guidance, which reserves medication evaluations for children 12 and up with obesity, and reserves surgery evaluations for children 13 and up with severe obesity.
BMI has been criticized as an inaccurate marker for health, as it doesn't take into account someone's frame, muscle mass and other factors and does not predict individual health in a fool-proof way. It also doesn't account for the role fitness and physical activity play in overall health, regardless of weight. In instances of the "obesity paradox," people with a higher BMI have fared better against severe disease outcomes in some instances than lower-weight people. This suggests that weight and health are connected in a more nuanced way than both medical providers and the general public have been taught.
Not everyone agrees that a high BMI should be classified as a disease or require treatment in itself, including many in the fat acceptance community who view fatness, in part, as one form of bodily diversity. And not everyone is comfortable with the use of the word "obese" in the first place, including people who have experienced its negative connotations firsthand.
"Many people that I work with who have lived experience in eating disorders -- where they've had their own eating disorder, they've had loved ones with an eating disorder -- consider the term 'obesity' to be an expletive because of the harm that has been caused either to them directly or a loved one," Hill said.
Rutherford doesn't particularly like the term "obese," and definitely not "morbidly obese," which is considered an outdated term by many in the medical community as well. (You wouldn't say someone is "chronically diabetic.") But Rutherford supports the view of obesity as a disease, because classifying it as such has the potential to protect children from harassment over their weight, Rutherford says. Embracing obesity as a health condition forces it under the same considerations by the American Disability Act as other common mental and physical health conditions, including major depressive disorder and diabetes.
Basically, teachers would understand that Rutherford was fat and needed medication "because of disease, not laziness," they say.
"My childhood would have been so different," they said. "These things would've had my back instead of being 14 years old and having my own back."
The thorny discussion around classifying obesity as a disease is just one example of how definitions can shift over time, and the list of physical or mental states that qualify as a "disease" is far from static. There's also an ongoing conversation around mental illness being just like any other illness, and whether that better-serves affected people or inhibits them.
Tigress Osborn, the chair of the National Association to Advance Fat Acceptance, supports a fat person's right to do whatever they want with their body -- including lose weight. But she warns that the choice to do so is never a neutral one. Outside pressures to lose weight come in many forms, like being unable to fit in a movie theater seat or being less likely to get a fair ruling in court, not just wanting to slim down.
"These are not choices that are made in a vacuum," Osborn said.
These barriers to a fair life, combined with the imperfect notion of BMI and the value of body diversity, means that obesity isn't a disease in her eyes. Rather, the urgency should be redirected to society to improve the everyday access issues that prohibit fat people from being accepted exactly as they are.
"Just protect fat kids," she said.
But Osborn recognizes the relief someone can feel by subscribing to the idea that their body is large because they have a disease. "It is life-changing to a lot of fat people to be told for the first time in their lives, 'this is not your fault,'" she added.
Our culture has been grappling with an idea of beauty and thinness that not only targets adults with weight-loss medications or ineffective nutritional guidance, but also exposes children to the idea that in order to be seen and respected, you have to be thin. And while this is an idea so deep under our skin it will take effort to peel back, there have been steps, including more serious considerations about the effects of anti-fat bias as well as some change to how bigger bodies are represented in media.
One very simple step in progressing the conversation, according to Rutherford, is to stop interjecting with a "no, you're beautiful" when they call themselves fat.
"I know I'm a pretty bitch, but I'm also fat," Rutherford said. "Those are not mutually exclusive."